2015_1207 IRRIGATION � DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and dated original
must be submitted to the public water supplier for recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS LD. #0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE: ��l,�O e
LOCATION OF SERVICE: �1- f�rt� A
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certi,fied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
i:JReduced Pressure Principle ❑Reduced Pressure Principle-Detector
❑DoubleCheckValve ❑Double Check-Detector
ClPressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer � ��� Model Number �✓`� Size�
Located At ��Q�/� �}�r'CC�(�(i� Serial Number ��� Z 3 Z�l�
�
Is the assembly installed in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at�psid Held at�psid Opened at Opened at Held at
Initial Test Closed TightCl Closed Tight ❑ psid psid psid
Leaked❑ LeakedC:l Did not open ❑ Did not open ❑ Leaked❑
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight❑ ClosedTight❑ psid psid psid
Test gauge used:Make/Model ��ll�j �►-� SN: �(� �7
Date Tested for Accuracy: 1_����— /'�
Remarks:
The above is certified to be true at the time of testing.
� � Firm Address ��( GLi ��I �/2--
Firm Nam ����� ��,
Certified Tester(print) �� ��-��� Certified Tester(signature)
Firm Phone# ��2 � 1 � I� Cert.Tester No.������. Date `li 7��
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy
GANDARA IRRIGATION INC.
3901 Clifton Dr. Richardson TX 75082
Office: 972-671-3776
Fax: 972-664-9158
Cell: 972-467-3918
Email: eddiegan1@sbcglobal.net
929 SARATOGA BELMONT LANDING
COPPELL TX
To Whom it May Concern;
An irrigation system was installed at the property described above. In accordance with
the city of Coppell inspection requirements, we are providing the following information.
This irrigation systemhas been installedin accordance with all applicable
State and local laws,ordinances,rules,regulations and orders.
I have tested the system and determined that it has been installed according
to the irrigation plan and is properly adjusted for the most efficient
application of water at this time.
1 year warranty from the day of installation.
Sincerely
EDWARD GANDARA
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